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10 Articles in Volume 9, Issue #8
Adjunctive Psychiatric Pain Management Treatment
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 2
Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain
Intradermal BTX-A Reduces Frequency and Severity of Pain for MMD
Keeping Prescribers on Board if Certification Becomes Part of REMS
Magneto-Laser Therapy of Pulpitis and Vertebra Column Osteochondrosis
Pain and Self-regulation
Pain Care of Severely Neurally-Compromised Patients
Simultaneous Use of Opioid and Electromagnetic Treatments
The Experience of Pain

The Experience of Pain

Health, health care, evidence-based medicine, and the metrics paradox.

We hold ideas that are as familiar to us as the coins in our pockets. Every now and then it’s useful to take those ideas out of our pockets and think about their validity and about their value. Two events that dominate our political and our professional awareness coalesce and prompt me to reconsider how we assess and treat painful conditions such as CRPS in the larger context of health care. Our health care system may be so fraught with economic, moral and political conflict that meaningful reform might be impossible. When health care reform becomes limited and piecemeal, social and moral considerations will be replaced by technical ones. At the same time that the conflict over health care reform reaches crisis, witness the maturation—not necessarily in the best sense—and the publication of Cockrane-model analysis of what is now enshrined in the health care bureaucracy as Comparative Effectiveness Research (CER) and evidence-based medicine. Evidence-based guidelines hold the promise of establishing “best practices” that will make diagnosis more accurate and treatment more rational and efficient—that is, less costly.

At the intersection of these two events—the current debate on health care reform and recent publications of evidence-based guidelines—I seek to raise the following questions, though I may not set down proper answers:

  1. What is health and what is illness?
  2. How does pain affect the experience of health and illness?
  3. What is the place of health care, and, therefore, of pain care, in the social contract (the rights and responsibilities of each individual in society)?
  4. If pain cannot be measured, how can society rationalize pain care for each individual patient whose experience it cannot know?

Defining Health and Health Care

The fury that rages around health care reform comes, in part, from confusion about what really is health care. More importantly, no one seems interested in defining health itself—no less in declaring the reciprocal role of society and health care—before everyone offers various prescriptions for reforming it. Starting with the definition of “health,” the reliably unreliable Internet defines health as “a healthy state of wellbeing free from disease.” Merrian-Webster offers this: “the condition of being sound in body, mind, or spirit; especially: freedom from physical disease or pain” (italics by Merrian-Webster).

A proper definition of health should declare what health is, not what it isn’t or what it lacks, as in “free from disease.” The World Health Organization (WHO) tried to rectify this flaw when it defined health in 1948: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” WHO’s Ottawa Charter for Health Promotion (1986) further proposed that health is “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities;” and finally: health is “the overall state of physical, mental, and social wellbeing and not just the absence of disease.”

Such definitions are inadequate because they are circular; they equate health and wellness or wellbeing. A synonym is not a definition. Health, wellbeing, and wellness stand in for each other. Generally, health is considered a condition or state that can be good or ill. In such a case wellbeing is a synonym of good health. Good health is wellness, bad health is illness. Neither constitutes a definition.

Several dictionaries make a good try: Random House (1967), “The general condition of the body or mind with reference to soundness and vigor,” and the Oxford English Dictionary (OED, 1998), “Soundness of body, that condition in which its functions are duly and efficiently discharged.” These are positive statements of what health is without too much circularity. Both of these definitions defines health as a condition or state of the individual—a state of being. One might better think of health as a process—a composite of dynamic functions, not static ones. To this end the OED gets close but not close enough. The 1986 Ottawa definition got closer. If we view health as a momentary condition of the body, of the mind, or of the spirit, then health care is a disjointed series of investigations and interventions into that state of things. We treat conditions and diseases instead of treating people who suffer them.

In his new book, Technological Medicine: The changing world of doctors and patients,1 physician, historian and ethicist Stanley Joel Reiser makes the convincing case for defining health as the ability of the individual to adapt to the physiological, emotional, social and ecological world with whose imbalances and perturbations one must contend. To paraphrase Reiser, health is the capacity of the person to flourish in the face of adversity. The definition does not assume mind-body-spirit unity, but it applies whether or not one views “personhood” that way.

The “person” is bounded by the biology of a beating, breathing, energy-consuming and -producing body that is situated in ever-widening relationships: internally among chemicals, cells, internal organs and systems, and external to the body’s boundary among family, community, work, society, culture, moral and spiritual predispositions, the environment, the ecosystem and realms beyond. George Engel described this layered, onion-like set of spheres of the human condition in 1977 and introduced the “biopsychosocial” model2 as an alternative to the prevailing biomedical model of disease. The biomedical model views health care as finding and treating disease, including injury and deformity. The biopsychosocial model views health care as the understanding and treating of illness—the effect of a disease, injury or deformity that causes the decline of the embodied and situated person, and this decline threatens or degrades the quality of life. In other words, health is the capacity to flourish, illness is decline.

Pain in Health and Illness

When a patient complains of pain, we observe the pain at some remove, not unlike trying to measure the redness of the red, ripe tomato from its photograph. For pain, “the thing itself” is nociception, and we are trying to observe the patient’s experience of nociception. Nociception is the transduction, transmission, encoding and storage as a neural representation of a stimulus. The experience of that representation was given two names by Phillip Lippe in 1998,3 eudynia and maldynia. Eudynia or “good pain” does not degrade the quality of life. Most of the time is passes without much notice or even enhances the quality of life in that it is being instructive and corrective of our behavior. Maldynia, or “bad pain,” on the other hand, degrades the quality of life by making the sufferer fearful, sad, angry and generally miserable.

Lippe’s classification of “pain” is much better than the traditional three-part classification found in much of the current literature. Two recent publications that persist in treating chronic pain as a disease entity are of particular interest to pain practitioners: The Guides to the Evaluation of Permanent Impairment (the Guides)4 and Occupational Medicine Practice Guidelines, 2nd Edition (Chronic Pain)5 published by the American College of Occupational and Environmental Medicine (ACOEM) (The Guidelines). The Guides classifies pain into a) nociceptive pain, b) neuropathic pain and c) persistent pain as a disease entity (direct quotation of titles of sections 3.1a, 3.1b and 3.1c). To the Guides’ credit, it uses a measure of functional capacity-versus-disability as a measure of “pain related impairment” (PRI) and well defends its use. Nonetheless, the section ends with the breathtakingly superfluous statement that “… any decision about caps for PRI (maximum impairment rating in the 6th edition was raised from the 5th Edition’s cap of 3% to 5%) will be perceived as arbitrary.”

ACOEM does not classify pain in the same way. It develops guidelines for distinct conditions: chronic pain generally, complex regional pain syndrome, neuropathic pain, trigger points/myofascial pain, osteoarthrosis, chronic persistent pain and chronic non-specific pain syndromes. The rationale for this taxonomy is unclear. There exists a separate volume that addresses low back pain. Appendix 4 of the Chronic Pain volume bears the title: “Psychological assessment tools: a glossary of psychometric assessment tools and concepts commonly used for the assessment of patients in rehabilitation.” It lists 39 instruments in eight categories. The strengths and weaknesses of the ACOEM Guidelines are not the subject of this essay6 beyond declaring that a foundational assumption of the Guidelines—i.e., that pain is an entity or condition capable of measurement—is false.

Health Care and the Social Contract

Health, as Reiser and I define it, is the capacity of the embodied and situated person to cope, to adapt and to flourish. At what layer of Engel’s biopsychosocial model of the human condition does one search for the object of health care? Some will say that health is solely internal, and that no external agent is needed to provide or restore health. Some relationships of family and community serve, as for Christian Scientists, but society’s agents, neither professional nor bureaucratic, need apply. Others view health care as a human right and call on all agents at every level of social organization to provide the resources that promote health, limited only by the boundaries of respect, beneficence and justice, not cost. In the United States, most people are somewhere in between.

At the extremes, health care is: (a) the province of the individual human spirit and out of the reach of external agency, or (b) a universal human right that must be promoted and protected without prejudice or concern for cost. Between these poles, health care is: (c) an individual responsibility, (d) a benefit of employment, e) a right of citizenship, f) a right of residency, or g) some combination of these.

Some, if not much, of the distress of the American health care system is attributable to the fact that most Americans have health insurance as a benefit of employment. The tax advantages to both employers and employees began during the Second World War as a way of attracting skilled workers to war industries. An executive order at a time of war became law in the 1950s and repealing it now is virtually impossible. If health care is a benefit of employment as part of the social contract, then the social contract must provide for the unemployed—both retirees and the 4-6% of the workforce that must remain unemployed to keep wages and prices stable. It took an unconscionably long time, but Medicare and Medicaid filled that requirement.

“First and foremost, however, the discussion of health care reform requires a coherent definition of health and, from it, an understanding of the goals of health care for our society, for our economy and for every American.”

Fifteen percent of all Americans remain without health care insurance—employment benefits, Medicare, and Medicaid, notwithstanding. The self-employed can’t afford it. Many employers do not offer the benefit, or only offer it to full-time or salaried employees. The percentage of Americans without health care insurance varies with the definition, but one would think that such a large number would be a political force or, at least, a moral force in the political process. Even among Americans who have health care insurance, as many as 85% of them consider themselves to be “under insured”—a shocking statistic considering the cost.

A “libertarian” will say, and Ron Paul (R-Texas) does, that health care is not a right; it is an individual responsibility with charity providing for the rest. He would say that the role of government, if any, is only to insure that the rights of the individual to contract the care of his or her choice is not infringed or restricted. A “progressive” will say that any person who resides in the United States is entitled to basic health care. There are arguments about whether the benefit should accrue to all residents or just to legal residents, and some—who probably do not use the name “progressive”—would restrict the right to US citizens.

The American health care system winds up picking and choosing its philosophy for each type and sort of health care service. Each service has a place along a spectrum of appropriateness and necessity for individual mortality, health and the greater good of society. Thus, basic immunization against communicable diseases is provided to all at public health clinics, while almost all health care insurance plans decline to cover the cost of cosmetic surgery. Reiser points out that the way we pick and choose is dominated by technology, not what we should do, but what we can do. The basic health care that would extend or better the lives of tens of millions (return to the definition of health) is not a right, while the need for dialysis immediately qualifies anyone suffering from end-stage kidney disease for Medicare enrollment.

The logic that is applied to health care policy decisions is only as good as the assumptions with which the discussion begins. Those assumptions include each person’s moral intuitions, philosophy and understanding of the social contract. First and foremost, however, the discussion of health care reform requires a coherent definition of health and, from it, an understanding of the goals of health care for our society, for our economy and for every American.

Measuring Pain and How We Treat It

Our patients complain of pain and demonstrate its presence, and we think that we know what that means. Pain practitioners have a healthy tolerance for subjectivity since pain cannot be measured. We use the quip: “There’s no ‘algometer.’” There is no liquid crystal strip we place on our patients’ foreheads to demonstrate the intensity of their pain. Nonetheless, “pain” is now the “fifth vital sign” along with the patient’s temperature, pulse and so forth. Every health care student now knows that the measure for pain is a 10 centimeter visual analog scale for pain (VAS-P). It’s intuitively obvious that one would never use a VAS to record blood pressure. We have pneumatic, lazar Doppler and electronic instruments to measure blood pressure, respiratory rate and the other vital signs. These instruments can be validated for accuracy and for the repeatability of the measurement. The measurement can be recorded in the chart and shared among observers. One can determine inter-observer and intra-observer reliability for each method of measuring the patient’s vital signs—all, that is, except pain.

The VAS yields a real number to represent a subjective experience. It gives the illusion of objectivity. We say that observations of an object or event are objective when they yield measurements or recordings by a method that can be externally validated. Earlier, I compared the effort to measure pain to measuring the redness of a red ripe tomato from its photograph. If the red, ripe tomato is on the table one could measure the intensity and hue (frequency) of its redness. The instruments are calibrated against standard samples of intensity and hue of red. These are the hallmarks of an objective measurement. But if one had only a color photograph, a representation7 of the red, ripe tomato, then one could not observe “the thing itself,” only the representation of the red, ripe tomato. It looks “real” in the photograph, but it is not. Plato told us long ago that what is accurate is not necessarily true.8

When a patient describes their pain we perceive it at the same remove as when we see a the photographic representation of a red, ripe tomato. The VAS-P tells us something about the patient’s experience, but not much. Every pain practitioner knows that each person’s VAS-P is unique. There can be no comparison between two patients’ VAS-Ps, except as a measure of the variability of the experience of pain. Comparative Effectiveness Research (CER) relies on changes in VAS-P (ipsative assessment) without concern for the initial level of the VAS-P before treatment, which is, of course, why retrospective pain research is unreliable. The pain practitioner is critically concerned with each patient’s “level of pain” and the experience of it.

How the pain practitioner applies evidence-based guidelines based on CER to the care of an individual patient requires, in the words of Sidney Greenstreet in the person of Casper Gutman, “nice judgment.” Thomas Errico, in his presidential address to the North American Spine Society in 2003,9 made a convincing argument against the unquestioned used of evidence-based guidelines in health care. He proposes the process of “syntegration” as a contraction of the integration of information and knowledge from multiple sources to synthesize the best recommendations for each individual patient. Errico extols prospective, randomized clinical trials, meta-analyses and systematic reviews as necessary to the “synthesis” process; but he takes pains to warn against the uncritical acceptance of the synthesis of others.

In Technological Medicine, Reiser traces the influence of technology on how practitioners go about integrating information from patients—from Lannaec, to Roentgen, to the present. When Lannaec listened to heart sounds he was “hearing the disease.” He directly observed the defect that made the patient ill. From that moment, physicians have sought the physical impairment at the root of any medical condition that causes illness.

So it is with painful disorders. We seek the pain generator. Technology permits us to identify physical impairments that are concordant with our patients’ symptoms and that invite our technological treatment. The patient with sciatica in the pattern of spinal claudication with an MRI revealing sulcus stenosis on the same side is likely to receive epidural steroid injections when non-invasive treatment fails. If the epidural steroids fail, the practitioner may recommend decompression of the exiting and traversing nerve roots, with predictably good results. Scott Boden and colleagues10 warn that there are a lot of middle-aged people “walking down K Street” with worse looking MRI’s and no pain at all. Most practitioners think they know how to reconcile these observations, and I, for one, think they can; but how can we be certain?

The Metrics Paradox

The social contract demands that society cover the costs of health care by some combination of public and private risk sharing—by the name of “insurance” or otherwise. To prevent frivolous, capricious or fraudulent costs, “society” needs rational, valid methods of assessing the appropriateness and necessity of care. Society needs numbers. Patients need care; they are not integers.

Pain, as an experience that degrades the person’s quality of life (maldynia), cannot be measured. We have measures for associated phenomena (the 39 instruments listed in Appendix 4 of Guidelines) but whether an “associated phenomenon” such as depression is cause or effect is uncertain, and our understanding of the distinction changes with advancing science. Most pain practitioners agree that functional capacity is the best measure of the effects of pain, but that is not a measure of “the thing itself,” namely, the experience of pain. When chronic pain is viewed as illness and not as a condition, then the assessment and care of patients suffering from painful conditions will emerge from the push-button mentality that wants to put a number on a person’s suffering. That is the metrics paradox.

Last updated on: December 28, 2011
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